Episoe 39, Season 2. Chuck and Chris take a deep dive on another sports topic- thumb UCL repair. We discuss primary repair and suture tape augmentation. After a brief case introduction, we discuss the decisions the surgeon considers and the implications for cost and for recovery.
Reference mentioned:
Michelle Carlson, et al. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg Am . 2012 Oct;37(10):2021-6.
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Survey Link:
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Episoe 39, Season 2. Chuck and Chris take a deep dive on another sports topic- thumb UCL repair. We discuss primary repair and suture tape augmentation. After a brief case introduction, we discuss the decisions the surgeon considers and the implications for cost and for recovery.
Reference mentioned:
Michelle Carlson, et al. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg Am . 2012 Oct;37(10):2021-6.
We plan a newsletter launch soon. Subscribe here: https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Welcome to the upper hand, where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Oh, Hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm doing well. How are you?
Chris Dy:I'm good. It feels feels a little bit weird to do this again, in our normal manner, you know, back at home, we're not doing this in front of a live audience. It's great.
Charles Goldfarb:It's great. It's just me and you like old times.
Chris Dy:Like old times. We miss the old times, although it's been really fun. So I don't know if the ASHT episode is going to drop in time to supersede this one. It probably won't. We're still waiting on the audio. But that was an incredible meeting. So the hand therapy. Society was in St. Louis, this past weekend. And it was a great meeting lots of energy. And it was really fun to do a live taping of the podcast.
Charles Goldfarb:Yeah, it looked like fun. I was away at my daughter's parents weekend. She's She's a first year in college. And it was important for me to be there. And I was so happy to be there. But I carved out time and you thankfully, were present on site. I was present by zoom. It was super fun. And it looked like the it did look like the energy was great. And people were asking questions. It was awesome.
Chris Dy:I think it was fantastic. I truly enjoyed it. It it gave me a lot of it was very humbling, you know, to be asked to do something like that. And it gave me a lot of fulfillment to just be up there and kind of talk and I heard that there are people in the audience who, you know, really got into it. And they said that this is what we've been needing to have just surgeons, really speaking their minds, maybe with or without any preparation.
Charles Goldfarb:Yeah, I mean, I you know, part of the reason you and I enjoy this is that we are you know, just talking about how we think about things, you know, with good scientific basis, but having those conversations with our colleagues in different fields and different levels of training does feel good. I you know, it's super fun to interact with therapists and students and residents and the whole thing.
Chris Dy:A shout out, shout out to Dean Becky, you know, so she was a she was our, our guest and our moderator, I guess for the session and she did a great job mixing right in with us those of you that are listening will hear it next week. But I believe she used to work with you in the office. Is that right?
Charles Goldfarb:Yeah, for sure. Becky and I have known each other for a long time. I'm sorry, I didn't get to see her in person. She was in St. Louis at WashU. Well, I guess it was just Milliken hand therapy then and, and yeah, we worked closely together before she left to go north. And then now she headed east for Ilan, where she is a dean of Health Sciences. It's pretty awesome. I love her path.
Chris Dy:It is pretty impressive. And I'm sure it was nice coming home for her because I know that she also mentored and advised one of my dear therapy colleagues, Jamie Findice, who who was her student at Maryville, they called her Dr. Becky at the time.
Charles Goldfarb:It's kind of awesome. So I want to give you a shout out, a well deserved shout out. So I think the listeners understand how your career is, you know, going so incredibly well, clinically, you've established yourself as a nerve expert, and well deserved I think you're a good thinker, and you share your thoughts eloquently. You've written great stuff, you are funded at the highest level. So that's all great. And it's reflected in your promotion. So congratulations. So now you're an associate professor. But what's really important and some of you may be rolling your eyes, like who cares, it matters I care. It's really tough for a clinician to get promoted on the tenure track. Really tough. And so you have accomplished that in a time where for pedic surgeons to accomplish that goal, it's hard. And I'm really happy for you.
Chris Dy:Well, thank you, I appreciate that you even managed to say good things about nerve surgery at the same time. I appreciate that. It's, it feels good. It's one of those things where I'd been thinking about it for quite some time. And I'll be honest with you, you know that the tenure track stuff was a bit trying it obviously made it more challenging to achieve that bar. But I'm very proud of it. Now. You know, I was I was asked to give a talk at the clinician scientist program for the orthopedic Research Society. And the talk they asked me to give was on promotion and tenure. And I don't know if that I don't know if they knew that I had just been promoted at the time they asked me to give a talk and I don't think they knew whether I was on the tenure track or not. But I did a lot of research into what tenure means in 2021 at academic medical centers and in surgical department. The answer is that it's highly variable. You know, it's a, it's a, I don't know, to me, it feels good. I don't know what it does for me outside of that, but I do like the badge of honor. Perhaps I've been conditioned that way, but I do like it. And so I got the letter of tenure when we were at the hands society on that Friday. So when I shared it with my family, I came home and my kids had made sign saying congratulations, it was great. And then I asked the I asked my son, I said, He's six. I said, Rafi, what do you what are you congratulating me for he said, you know, cuz you got your, your, your 10 thing? Like, I was like, What do you mean? He's like, well, it's got to be good, because it has 10 in it. All right, perfect. They said, I said, Well, why Why do you think I got it? And he's like, because you're a really good teacher. Like, alright, I'll take that. That was probably one of the best definitions of the worth of tenure that I've that I've heard.
Charles Goldfarb:He got it right. And it is interesting, again, for those not in academics, tenure in 2021 for a surgeon, honestly, you know, we think of tenure when we're talking about college professors. And it's a big deal. It means their job is secure. Tenure for us doesn't really mean all that much. It doesn't necessarily change our job security, but it is, it is absolutely important to the process. And so it means a lot. So congratulations, and enjoy it.
Chris Dy:Thank you, I will and you know at our place that hopefully that's the biggest jump is from assistant to associate with tenure and we'll see where it goes from there. You know, not all of us can be you know, full professor with the Weiland metal hang- where, why aren't you wearing your wildland metal I wanted hanging on here. So those of you that are watching on YouTube Chuck is not wearing his Weiland medal, which is a shame because I actually if I were you, I would get it made into like a WWF Championship belt style.
Charles Goldfarb:True, that's a good idea. I may have to look into that.
Chris Dy:Yeah, I'm sure the hands society provides funding for that. But anyway, why don't we jump in? You know, I think that there's a lot we could share. But we really love getting listener feedback from our community. And everybody loves these deep dive episodes that detail episodes. So you have another one a day. And everybody loves sports, apparently. So we're doing another deep dive on a sports thing. But we had a great email from this is fantastic Chuck, a consultant orthopedic and trauma surgeon in the Greek army. It's amazing. So Major Yannis Lacanas. Thank you for your email. And he had a question here. So he says in the deep dive episode about SL injure you mentioned the hypothetical patients X ray show no SL widening, but maybe a bit of dorsiflexion of the lunate. But dorsiflexion of the lunate independent of the scaphoid should only happen once the two bones are completely separated. And probably after all the secondary stabilizers have failed, right? So can there be a circumstance that one can see the radiographic appearance of DISI with a well preserv d relationship between t e scaphoid and lunate int e coronal plane, you know o gapping, in the absence of a scaphoid fracture or non unio? So Chuck, what do you think I m the one who gave you the case? I admit, I have seen that, y u know, so no widening but so e dorsiflexion. What do you wh t do you think about that? And h w can you explain it to me knowi g that you're the expert her
Charles Goldfarb:Well, first of all, thank you so much for the question, and it is a good one. And it's not an easy one. Let's start by just saying what are the radiographic parameters which are indicative of a complete SL tear, with loss of secondary stabilizer so just let's set the floor. So if you have that situation, you will see why being of the SL interval classically more than three millimeters, you will see flexion of the scaphoid classically more than 70 degrees, so scapholunate angle more than 70 degrees. And the other side, we talked about the ring sign, which is seen on a PA radiograph, which indicates flexion of the scaphoid because you're catching the distal scaphoid or the tuberosity on fossa, and so you get kind of a ring looking appearance. So those are the three classic signs. I agree that it's hard to explain dorsiflexion of the lunate in the setting of an intact SL, or at least partially intact SL and intact secondary stabilizers. The tricky part, of course, is that the secondary stabilizers are really hard to understand. You know, we don't get information classically from radiographs about say the ST ligaments, the scaphotrapezial ligaments, we don't get we can get some information about the dorsal and volar contributions to scapholunate stability, but in all likelihood, in your case, there were secondary stabilizers which were compromised without a full tear of the SL, that would be my expectation.
Chris Dy:Do you think that if you had compromise some or many of the secondary stabilizers with a tear of the dorsal and central portions of the SL, but you still had some volar fibers of the SL intact. Do you think that scenario could happen? And do you think that scenario could lead to the point where you're not maybe getting widening of the scaphoid and the lunate interval, but you're getting some of that rocking back of the lunate and flexion of the scaphoid?
Charles Goldfarb:Yeah, well said I kind of had a similar situation today. But yes, you get some rotation around the intact portion of the SL ligament. If that's volar, then that's exactly what you see. And that's very similar to what I saw today in the operating room, leading to a, you know, repair situation. So it's a good question. It's important question, I have to say, it's not fully understood. But that's the way I knew and I seem to think about this the same way. And that's how I think about it.
Chris Dy:Now, Chuck, there's more Major Yanis continues to ask us. Also, what would be your preferred treatment of a chronic maybe over one year dorsal wrist pain patient with an unremarkable exam and the MRI shows a possible tear of the membranous SL? Assuming all non operative portions that failed, would you scope and if you did scope, what would you do with this portion of the ligament? Now before I let you answer this, you have taught me a lot about kind of this nebulous and nagging pain that could be related to a volar SL or like Yanis was saying a membranous tear. And I don't think there's a great solution. But again, you're the you're the genius in this area. So what do you what do you think?
Charles Goldfarb:Yeah, I would think that is high praise. In fact, to high of praise. I would say this. If all conservative treatment has failed, I do believe a wrist arthroscopy is logical. You know, the problem with open treatment of something Oh you already know, I knew I knew you were gonna talk about like this is if your dorsal and volar ligaments intact, you know, what are you really going to do open plus you risk destabilizing even a ligament sparing approach, I do think compromises some of those secondary stabilizers like the DIC, the dorsal inter carpal ligament, potentially the dorsal radiocarpal ligament, so a scope is has minimal negatives, and a lot of potential positives. And the way I've thought about it, is that debridement of that rea can take care of the pain, hich is part of it, and I don't esitate and this is highly, ighly controversial. There is iterature support for it for ure. Peter Weiss has written bout this amongst others, but eat shrinkage of that- that thermal- thermal shrinkage. But it's a very limited thing. And I think part of it is just the you're you're cleaning up the fibers because you don't need that membranous portion. If you're dorsal volar intact. If you're stable. I don't know what exactly we're accomplishing. But it feels good to be doing something.
Chris Dy:So do you just like make a portal and put the bovie in and just turn it off to like 100 just zap that thing? Like, what do you do exactly?
Charles Goldfarb:That's kind of what we do it's like the little nerves like when we do a carpal tunnel, we just buzz the nerve, if it starts to acting up.
Chris Dy:Oh man, every time I every time I watch our residents do the dissection and shout out to Paul Inclan, he took the challenge the gauntlet that we threw down about the old school resident dissection and really took it to another level with his dissection this week. So thank you, Paul. But every time I see one of our residents moving around a nerve and a cadaver, just grabbing it with the forceps. Not to say you did this, Paul, others have. It's just I get a little chest pain. So I you're striking a nerve here, no pun intended.
Charles Goldfarb:Yeah, there is a little refinement of the technique, but there's a small joint wand or probe that you can selectively and under a significant irrigation apply heat to that membranous portion of the SL. Does it add anything beyond a debridement? Honestly, I don't know. But it has been effective in my hands with certain patients. It's a pretty rare scenario where you can't get a patient better with just a membranous tear, but it does happen.
Chris Dy:Well, Major Yanis I hope that Chuck has answered your question adequately, please let us know if he hasn't and shout out to everybody who has sent us emails. We love the listener mailbag. So handpodcast@gmail.com. We have a few emails in the queue to read lots of questions to Sandra Stiller, Josh Husthet. Bob Vandermark and Brittany Mitchell, you're coming up soon. And we may just have to have like a fan mail episode for where we answer all these questions.
Charles Goldfarb:Well, I think that's that's that's when you when you hit the big time you have a mailbag and some of the sports podcast I occasion listen to have that that would be fun, be totally fine. I have two comments. The first comment is-
Chris Dy:Of course, two things. Classic.
Charles Goldfarb:Yes, two things, not one, not three, two. Please sign up for our newsletter, which is impending. And so if you go to any of the podcast, show notes, there's an easy link to follow. We would love for you to sign up and Chris and I plan a newsletter, which hopefully will be fun and informative. That's number one. Number two, is a question for you. What does the number 105,000 mean to you?
Chris Dy:So this, that actually gave me a little bit of PTSD to a moment in fellowship, where Dr. Gelberman wrote a bunch of numbers down. And he literally looked at me and said, What do these numbers mean to you? I'm gonna guess that it is what you got. When you got promoted from associate to full professor about five, six years ago, I don't know.
Charles Goldfarb:A bonus? No, there was no bonus with that.
Chris Dy:Oh so I don't have much to look forward to then?
Charles Goldfarb:Oh, financially? No. The 105,000 is our current download number. So we are so thankful for all of you, listeners, we have 105,000 plus downloads, which is really remarkable. So we are grateful and we are proud.
Chris Dy:That is fantastic. So we, we love it. Thank you to everybody for listening. The outpouring of love for the podcast at the hand therapy meeting at the hand society was incredible. It continues to drive us so thank you for listening. And of course, tell your friends, we're actually out of swag, which is incredible. It just went away quickly at the hand therapy meeting. And I do have a few that I have to send overseas to the surgeons in the UK who helped take care of our friend and partner Dr. David Brogan during his visiting fellowship. You know, it's it's amazing. So thank you for listening. And we won't torture you longer before we drop into this episode. So let's talk about some deep dive and detail into... Thumb UCL.
Charles Goldfarb:All right, I love it. I love it. And I think it's a good topic. Because I do feel like compared to five years ago, most of us, at least amongst our partners think about this slightly differently. So let me give you a case, and we can talk through it. So let's take a 25 year old who was playing kickball and kickball is a dangerous sport. I think all the listeners know that kick and often it's the 35 year old who may have been you know had a beverage or two. But kickball is usually on a crappy field. kickball is dangerous. And so this kickball player was a little younger, and he was rounding first for a hopeful double tripped, fell and jammed his thumb into the turf. And his day job is accounting. And he's worried about typing. It's 10 days after his injury he comes in his thumb is still swollen, his thumb is sore and you are concerned about a UCL. I know we don't want to get too much into the diagnostic process. But just tell me how you briefly how you think about it. And then let's jump to the next steps.
Chris Dy:I mean, I clearly am going to take a good history and ask if he has a side gig as a gamekeeper because clearly that's pertinent positives and negatives. I'll also ask him if he likes to ski because you know, that's also pertinent in this situation. But in all seriousness, you know, I think that point tenderness is big, and then it comes down on the physical exam to, to assessment of the integrity of the ulnar collateral ligament. Now we're classically taught that there are two components of that ligament complex, the proper UCL and the accessory, UCL. And in order to, to stress the proper, you should flex the MP joint down to about 30 degrees. And in order to stress the accessory, you do that in extension, and that's because that accessory tends to run as more of a horizontal ligament that is fibers at least then the proper tends to run more obliquely. I always check a side to side exam. And I know that there is some variability even in asymptomatic patients side to side. But I do like to check out side to side so I can warn me basically I tell the patient Hey, this is what I'm going to do on your other side. I'm gonna start here so I get a feel for what's going on. Now I know that one of our former partners, Dr. Gelberman, did write a nice paper with Kathleen McKeon looking at whether you needed to stress in flexion and extension, and I believe his take home was really if you really just need to check in extension, but I tend to check in both. What do you think?
Charles Goldfarb:I tend to check in both as well, I tend to compare it to the opposite side. I try to do it all under C arm. I just think it's an easier one step process where you can actually better quantify and we can talk a lot Ryan Calfee has wrote has written a great paper looking at the kind of rotatory and translational instability which can accompany an ulnar collateral ligament tear the MP joint. For simplicity, let me give you two facts. The first is that there is gross instability. There is no doubt that the UCL is ruptured. And he lets you examine him, although it hurts, and you are really concerned about the presence of a center lesion. So this is kind of your classic situation, acute rupture, seemingly from the base of the proximal phalanx, possibly with a center lesion which would preclude healing even in a cast. And so you are planning to take this person to operating Do you need an MRI?
Chris Dy:Need know what I get one? Maybe that's an honest answer. I think a lot of it depends on how confident I am on my exam, you're making this seem like it's an open and shut kind of situation. I'm assuming fluoroscopically you see that radial translation of the proximal phalanx when you stress them? So I feel good about this, I probably tell them look, you know, there are possibilities of false negatives with an MRI as well. Why don't we if you think you want me to stabilize this for you, as soon as possible, let's go for it. If you're having any hesitation about whether you want surgery or not, and you want to see if there's any capacity for healing with non after treatment, actually, then getting the MRI in that situation can be useful to help inform care and make sure Hey, look, there's no center. But an ultrasound can also do that for you, if you're in the right place. What do you think?
Charles Goldfarb:I think that's well said I think we probably over utilize MRI for this diagnosis in 2021. But I like the way you set it. You know, if you have a complete tear of the UCL without a stinner if you cast this patient, it should heal. But it's just not quite as reliable as surgery in my view. And obviously if you have a center where that where that UCL is rolled up and precluded from from reaching its attachment point by the adductor aponeurosis, then you then you really need to do surgery or you will remain unstable. So for this patient, I would not get an MRI. And I would go to the operating room. So so the facts are we have a young patient, 25, acute tear. And the question is, how do you do it? So let's talk through briefly-
Chris Dy:Wait timeout. Before you go on to this, I know that we're in a surgical detail episode, but for those of you that are less experienced, you know, Chuck, can you tell us you know, I like I like in a center lesion to somebody snapping a window shade and the ligament rolling back behind the 8-0 aponeurosis. I admit I'm awful with analogies, but everybody seems to get that one. And then secondly, for those that are more junior listening, why does it matter to have a thumb UCL.
Charles Goldfarb:Yeah, and the thumb UCL is different than the thumb RCL or radial collateral ligament, if you can imagine every time you pinch between the index and the thumb, you are stressing your thumb UCL. And without that, you're you can't obtain the same degree of pens, even with secondary stabilizers. And so you will lose pin strength, and you will develop arthritis over time. And those are pretty factual statements. But they're I feel very comfortable with so leaving it alone. So leaving it alone, to me is not a great option. But to be very clear, that acute pain will go away. So the pain will get better at three to four weeks, the patient are probably feeling pretty good, but I would argue is still not the right thing to leave them alone.
Chris Dy:Okay, so say we've indicated this patient, what are you asking for when you book the case?
Charles Goldfarb:And that's one of the million dollar questions. And so we know that this patient will do well with a repair. And we can talk about how to get there. But what I'm asking for is, for most patients, I do more than simply put the ligament back down to bone, I use suture tape to supplement it, that adds cost. It doesn't really add time. But like many things we do in 2021, the recovery period is dramatically different with the suture tape versus without it and so that's why I like it, but and use it most of the time, but not 100% of time, would you in preparation for this plan on suture tape or in a patient like this is the simple repair good enough for you?
Chris Dy:So I think that I've been now been spoiled by the suture tape, I think pre you know suture tape coming around or if they worked in an ASD where you know, there wasn't available due to cost. My old approach would have been to put the ligament back down to bone because you know, and about 90% of the time it's off of the proximal phalanx, put it back down the bone with the suture anchor of the mini type size. And I've usually pin and I would remove the pin at about four to five weeks I'd leave it out of the scan and remove it in the office. And I was satisfied with that. It worked well. Granted, I'd only been in practice I think probably three or four four years before switching over to the suture tape. The big difference to me is that the suture tape makes me feel a little bit better about not pinning the joint and leaving that pin. Now I don't know whether I could have just used an anchor and not pinned it. You know was that your What was your practice prior to suture tape because some of our listeners may not have access to it or may not be familiar with it.
Charles Goldfarb:Yeah, I the only time I have pinned is with a reconstruction with a tendon graft reconstruction. I do not pin with a primary repair. So if I chose to treat this patient if this patient was self pay and didn't want the extra $1,000 or so for the suture tape, then I would simply repair it with the suture anchor, I wouldn't pin but I would immobilized for four weeks probably before getting him moving. But the suture tape kind of removes a lot of those questions.
Chris Dy:So from an approach perspective, you know, the way that I was taught was to make kind of a curved s-shaped incision, paralleling the course of the ligament along the ulnar side of the MP joint. I of course this is my favorite part of the case dissect out the small cutaneous the dorsal branch to the thumb and protect that now I do warn patients ahead of time that they will feel numb on that portion of the thumb even while we dissect it out and protect it the you know the traction on it and pushing it out away does cause some sensation disturbance. Comes back. But I found out the hard way to warn people about that.
Charles Goldfarb:I think that's an excellent point. That's the first thing I do in size the scan a little s shaped incision centered at the MP joint find that cutaneous nerve and you got to keep it safe but it can be one of those classic situations where it gets it gets irritated once I insize the adductor aponeurosis longitudinally. I put a little skin hook in the adductor aponeurosis dorsally, that dorsal limb, and it protects that cutaneous nerve during the rest of the procedure. But most people will be irritated or complain about a little numbness and it goes away. For some people counter intuitively some athletes it can be bothersome to really to have that little area of numbness or or tingling, although again, it gets better as long as you protect the nerve.
Chris Dy:You know for the adductor aponeurosis. One tip that Marty Boyer, our partner taught me when I was his fellow was to take the marking pen and put a purple mark on the adductor aponeurosis, and then I have then adapted it to blot it dry so it doesn't run. But I found that to be helpful to find that tissue layer to close back later, perhaps you're just more gifted because you've got fancier loops than I.
Charles Goldfarb:I must have fancier loops, I don't feel the need to use a marking pen. And I think it generally presents itself but, no qualms and certainly no harm in doing that, once the now before we inside the adductor if there truly is a center lesion, so that collateral ligament is balled up proximally, it just looks everything looks a little confusing. When you get in there. It's just that the clean pristine anatomy is not there. But when you release that adductor, you kind of get a sense of Okay, I understand what's going on. Here's the standard lesion the balled up ligament, here's the joint, here's the insertion site, and you try to unfurl that, that ligament and bring it back and make sure it reaches the base of the proximal phalanx.
Chris Dy:I'll admit, you know, because I'm not typically the one holding the knife at that stage, I have the trainee insize the adductor, in line with what I think the UCL fibers, the proper UCL fibers should be running, just in case, because sometimes we're not sure. So I think I feel it makes me feel a little better. And as they're dissecting layer by layer, you start to see things declare itself a little bit better, you can clearly go more proximally on the metacarpal origin of the ligament, but it just becomes harder if it's truly curled up on itself. But to distinguish the anatomy,
Charles Goldfarb:I think that's well said. And you obviously want to protect the ligament and then all of a sudden you're down in bone. So if you're just going to perform a suture anchor repair, there's not much to it. Well, if I choose that approach, I put some type of mini suture anchor that doesn't really matter which one honestly, into the base of the proximal phalanx more volar than dorsal Michelle Carlson has a good article about the exact specifications of where the footprint is just off the articular surface. I personally like a little crack our weave into the collateral ligament, bring it down the bone and you're done. Is that how you approach it if it's a suture anchor repair?
Chris Dy:Yeah, same way. I was actually in Michelle's lab when she was doing that paper. I didn't write that one. But I worked with her research coordinator. So I'm familiar with that paper. And you know, I believe the take home was it's about three millimeters dorsal from the volar lip of the proximal phalanx and three millimeters distal to the articular surface. And that that was a really helpful paper for me to be able to localize that anatomy. Obviously, you don't want to be too close to the joints, standard suture anchor kind of technique. And yeah, whatever. Whatever suture pattern the ligaments will give you. I have a question for you. One of my other mentors in residency would in the setting of elbows would say if it's an acute tear of a ligament, no matter how long it's been, you should be able to repair that ligament back down the ligament should still be of good quality on the cases where you've gone in a little bit delayed. Have you found the ligament to be of reasonable quality to repair? And what triggers you to start thinking, oh, maybe we need to do reconstruction.
Charles Goldfarb:Yeah, you know, I guess 10 years ago, there was a lot of conversation of, you know, what happens if you're taking care of an athlete, and there's five weeks left in the season? And he or she thinks they can play through this? And you want to repair them after the season? Will there be enough collagen? Will there be a sufficient ligament to get that repair done? And the answer is, I don't know, I think in 5, 6, 7 weeks, you may be unsatisfied with the primary ligamentous repair. And so that's when I start thinking about our reconstruction. Or if there's reasonable collagen, but not perfect, I may accept, putting the residual ligament down. And supplementing with an internal brace really is about the amount of collagen there. And if there's just really nothing there, then I am not comfortable with an internal brace alone, I would add upon as long as or some type of tendon graft to supplement with a with a with an internal brace or suture day.
Chris Dy:Now do you ever consider I've never done this? But do you ever consider any of the dynamic reconstructions or dynamic stabilization of the UCL if you can't do a primary repair of the of the collagen?
Charles Goldfarb:I haven't so people talk about advancing the adductor. For me, No, I'll use palmaris and supplement it with a suture tape.
Chris Dy:So say for example, do you ever when you're putting in your suture anchor for this, and before you tie down your ligament? How are you doing this in terms of making sure the joint is reduced? Because we know not only that the proximal phalanx wants to translate radially there's this angular kind of gapping. And perhaps like you mentioned earlier, a little bit Angular, and sometimes some volar subluxation of a p1 relative to the metacarpal head, when you're doing this, who's holding the reduction? Are you pinned? I'm assuming you're not based on what you're saying before but who's holding it who's tying down the the the ligament?
Charles Goldfarb:So I think it's a great question is one of the pearls that I feel like has helped me a great deal is I do intra operatively pin these patients. And so I obtained an anatomical reduction of the joint, perhaps slight over reduction, meaning the proximal phalanx is tilted a little bit, in the ulnar direction, and I hold it with a K wire, which I removed before leaving the OR, I have found it really difficult to manage the three dimensional reduction while inserting the suture anchor and the suture tape and I you can get it done for sure. But it usually takes more than two skill sets of hands, you need three skill sets of hands, and I think it's tough. So I've been really happy with interoperative pinning.
Chris Dy:Oh, thank goodness, I'm not the only one feel much better now. I pin, I pin it, I get the reduction. I do a little bit of overcorrection you know, checking all planes, and I pin it just makes my life a lot easier.
Charles Goldfarb:It does and I think there's there's no harm to the joint with a single you should be able to place that pin on the first pass. And I consider it no harm whatsoever. I think the other pearl is how do you manage both repairing the ligament down to bone and putting your suture tape in. And so for me and I'm interested in your thoughts, I don't I try not I found I agree I found the tension tensioning to be a to use the biggest anchor for the base to proximal phalanx, but I put that anchor in first it's loaded with suture tape and suture and the joint is reduced and pinned. And so I have one limb of the suture which I it's now secured with the suture tape at the base of the proximal phalanx and I use that as a you know, Krakow weave or wh tever to bring the ligament do n. It's a little tricky with te sioning and you got to kind of think about how it's going to si as you place your sutures. An then I placed my second an hor, you know really at that or gin site, you want to be ca eful not to disrupt the or gin, the ligaments, I used to go a little proximal, referring ba k to Michelle's paper, a li tle dorsal to the to the mi line on the lateral view. And I heck a C arm for the placement f that K-wire. And once I'm appy with that, I drill and hen I dunk the suture tape into he metacarpal just proximal to he origin of the collateral igament. little bit tricky with this particular implant. Just the anchor tends to handle differently upon insertion and also running the suture through it can be tricky, although you know I've had plenty of cases where the tensioner works just fine. What I'd ask you is what size suture is in the anchor is it are you loading a 2-0 in there or a 2-0 something even more stout than a 2-0? Generally it's a 2-0. A 3-0 I think is totally fine in this situation. I don't think you want to go any bigger really you're just your goal here is just to have the ligament re approximated because it has the additional support of the suture tape so you're not really worried about it It means that you know being sufficiently strong I guess my other pearl would be as you place your suture tape I you know you don't want to over tighten this that's an error and so you can over tighten it and so what I do is I apply a gentle force and as I dunk the anchor into the bone I let go of the suture tape. So I've applied some force and I'm holding the suture tape over the the drill hole I've created and then I dunk the anchor into bone without my without holding that suture tape. And it seems like that applies a good force and it avoids over tightening but does provide sufficient support for the joint if you overtighten there's questions about stress shielding and whether the ligament will heal and whether you become too dependent on the suture tape which can lead to later problems so I've been happy and I think that tension is things well.
Chris Dy:Can you over tension it even while you're pinned?
Charles Goldfarb:I think you can because you know single k wire doesn't provide perfect stability I think you can but fair fair point fair point.
Chris Dy:Now I always have to remind our at least our orthopedic trainees we do also have plastic trained fellows as well that you can break a 2-0 suture when you're trying to slide the slide down your finger and not to use the classic orthopedic thumb when running your you know walking down your suture but to use something a little more elegant like an index finger but I have had those break and it is I sigh very heavily in the operating room tried to keep my composure but it is not a fun day at the office when that happens.
Charles Goldfarb:Oh no, I totally agree with that.
Chris Dy:And then one more thing before we go on. If for those of you that don't have access to suture tape, what was your pre suture tape suture selection for that anchor?
Charles Goldfarb:Something like a 2-0 Ethibond. I still think that's sufficient because really we're going to protect that patient in a cast. I used it when I first started I did it for six weeks I think that is not necessary. I protect them in a cast for four weeks and then I get them moving.
Chris Dy:So note if there's no suture tape pin across the joint single four or five or six two wire?
Charles Goldfarb:Doesn't matter for me because for me it's just interoperative I'm taking it out before they leave the OR.
Chris Dy:Oh that's right okay, gotcha. So in the OR what are you using?
Charles Goldfarb:4-5 usually.
Chris Dy:4-5 okay, and then you're there if there's no suture tape you are then immobilizing them for four
Charles Goldfarb:Four weeks and then get them get them moving weeks? would there be one other technical pearl which I should have mentioned when I pin the joint I mentioned slight over reduction but concentric reduction of the joint I do tend to put the joint in about 20 degrees of flexion when I'm pinning it to avoid losing flexion as they heal so you don't want to over tighten an extension because that's a problem and I've seen that happen I've been guilty of that I'm sure so that's a that's another technical pearl so slight over reduction slight flexion concentric joint reduction.
Chris Dy:Now do we make too much i mean i i always thought it was a big deal to make sure that the proximal phalanx wasn't fully subluxated Have you seen that to be you know much of an issue when you're trying to position these for pins or usually not a problem?
Charles Goldfarb:I haven't seen it'd be a major problem. So I repair the adductor aponeurosis you know close the skin protecting your nerve, Chris. The Chris nerve. I split I have them seen therapy within one week. A removable hand based splint get them moving. And the beauty of this for the athlete is this injury used to cost 12 weeks for sports. And while I get nervous, I think you can have had people playing full contact, full bore at six weeks ideally with a little protective splint. And you know the the wonderful example is Steve Shin's patient, Mike Trout was back playing in the minors at five weeks playing in the majors at six weeks Drew Brees as well. Unbelievable. Again, I like a little custom splint that doesn't get in the functional way. But that's remarkable. And you know, six weeks you and I would would hurt you know if we put in operate six weeks to professional athlete the difference between six and 12 weeks of getting back to play is a big deal.
Chris Dy:So when you talk about getting them moving. Now those of you watching on YouTube saw that video of Chuck kind of flexing down flexing his MP joint. When do you allow them to pitch?
Charles Goldfarb:I think I go slow, or I go slowly to be grammatically correct. They are moving in the plane of motion. And we're working on a edema control and basically just letting them be basically I tend to hold pins for five or six weeks. Obviously you probably don't need to do that, given the support of the internal brace but the question is why why why push it in most patients maybe an athlete struggling to get back maybe you do it four weeks but i do i don't start that right away.
Chris Dy:Are there any markers you used to know when the patient is ready to graduate from you know pinch free but moving into plane of the palm to when they can start to pinch is it when they have full motion or is it purely a time thing five six weeks
Charles Goldfarb:is purely a time thing. I don't think there's any great criteria. You know, I always talk to athletes about requiring three things before returning to play. One is full motion, second is full strength and third is no pain. These patients don't have pain you know from the second week so that that's off the table. They don't really check their strength super early. So it's really about getting that motion back first. And then when do we have confidence to let them go and certainly by six weeks we have confidence because not only is the ligament probably healed, you still have the internal brace and maybe a bit earlier.
Chris Dy:And maybe to milk one more technical detail out of you. Absorbable suture or nylon suture?
Charles Goldfarb:For the skin obviously I know I know we talk a lot about this and I am routinely disappointed with absorbable sutures. I really like the scar. I like the simplicity of nylons. Now in a younger patient you know where you don't want to take stitches out that's a different thing but an adult I typically use nylons here. You?
Chris Dy:It's interesting I will use in this particular scenario an absorbable suture and have not had any issues with it but in a different location. For example, the other day I was operating on the opposite side of somebody who had a carpal tunnel lip service. And typically when I do a carpal tunnel, I pretty much always do nylon sutures and effortless service the proximal median nerve decompression in the forum, I will use an absorbable monochrome. He didn't like the way that looked he had a little reaction to it. Still where the suture was exiting out. He clearly hadn't absorbed it in time. And when I went back to do his opposite side, I tend to look side to side to make sure my incisions are going to be reasonably the same length for my obsessive New York tendencies that I developed in residency. And he's like yeah, I don't I don't like this can you just use the absorb the nylon sutures like sure. Happy to you know, no problem.
Charles Goldfarb:Yeah, absolutely. I mean, we always you know, you get burned once with some railroad track appearance of the you know, the suture holes or the, you know, looking ugly and you wonder, should I be switching and doing subcutaneous in some particulars? I don't know. I just find complications, even if they're little complications, complications or less with nylon sutures.
Chris Dy:All it takes is one patient.
Charles Goldfarb:Alright.
Chris Dy:So any other any other great technical pearls you want to share? Are we out of out of Goldfarb pearls for thumb UCL?
Charles Goldfarb:I think I'm done. I think you now know everything I know.
Chris Dy:Data dump complete. So alright well next, so everybody, handpodcast@gmail.com Let's get the next deep dive topic requests. I'm sure it's gonna be another sportsy thing so I'll have to figure out what to do for that. But send us your suggestions, social media as well handpodcast on Twitter. So look us up or leave it in review, we would love to hear some questions and reviews, ask Chuck anything, literally anything.
Charles Goldfarb:Literally anything. And so we have some good episodes coming up. We're gonna share the flexor tendon discussion from the ASHT. I hope you and I've talked about doing a social media discussion about impact in the academic world and, and kind of profile building which I think will be super fun. We have a lot of cool cool topics coming up.
Chris Dy:Yeah, we have to get we have to get Jeff and Steve back our recurring guests that we haven't had back. I think it's time they had a great symposium at the hands society for called free solo. So we're looking forward to hearing how that went.
Charles Goldfarb:Absolutely. That sounds fantastic. All right. Well, it's fun catching up on a Wednesday night. I hope you have a good one. And I'll see you soon.
Chris Dy:All right, take care.
Charles Goldfarb:Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcasts
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.